Treatment of Oral Cancer in Germany

What is oral cancer?

Oral cancer is a group of malignant neoplasms found in the non-keratinized epithelium of the mucous membrane of the cheeks, palate, gums, floor of the mouth, or tongue. The pathology develops due to smoking, chronic infection, or chronic trauma: for example, poorly fitting dentures, or damaged and improperly located teeth. The development of oral cancer is often preceded by long-term precancerous diseases.

The most common histological type of oral cancer is squamous cell carcinoma. It accounts for 97% of cases. The most common remaining cases are usually adenocarcinoma, which develops from the cells of minor salivary glands.

In most cases, the first signs of oral cancer are ulcers, erosions, or cracks that cause discomfort when chewing and swallowing. Burning and tingling may also indicate cancer. As the disease progresses, 100% of patients start feeling pain. It shoots up the ear and temple. Due to the decay of the tumor, bad breath appears.

Diagnostic methods: 

• cytological examination of scrapings from the oral cavity and puncture samples of enlarged lymph nodes to confirm the diagnosis;
• instrumental tests: ultrasound, CT or MRI, as well as laryngoscopy and PET, if indicated;
• histological examination of the surgical material after the operation.

Principles of treatment

The main treatment method is surgery. It can be performed immediately or after neoadjuvant treatment. Preoperative therapy can reduce the size of the tumor and eliminate some metastases. However, a good response to therapy is not a valid reason to reduce the scope of the planned surgical intervention.

For some patients with stage T1 or T2, surgery will be the only treatment needed to cure the disease. At stage T3 or T4, or when there is the presence of risk factors for recurrence, postoperative therapy is required.

Characteristics of the primary tumor are as follows: 

• Т1 – tumor up to 2 cm with an invasion depth of up to 5 mm; 
• Т2 – tumor up to 4 cm with an invasion depth of up to 10 mm; 
• Т3 – tumor more than 4 cm with an invasion depth of up to 20 mm; 
• 4а – moderately, locally advanced cancer (invasion only in adjacent tissues); 
• 4b – locally advanced cancer, spread to the masticatory system, sphenoid bone, base of the skull, coverage of the carotid artery. 

With T1 and T2, the patient may require postoperative treatment in the following situations:

• positive resection margin; 
• tumor invasion in the tissue near the nerves, blood and lymphatic vessels; 
• detection of metastases in distant lymph nodes; 
• residual tumor if it cannot be removed during the second surgical intervention. 

Chemoradiation therapy may be an alternative to surgery. It is used in cases where surgery has been refused, as well as in patients who are considered unsuitable candidates for surgical treatment. Contraindications for radical surgery are as follows:

• direct spread of the tumor to the lymph nodes; 
• invasion in the skin;
• damage to the structures of the mediastinum; 
• invasion in the prevertebral fascia and cervical vertebrae. 

In these cases, surgery becomes risky, and complete tumor removal is unlikely.

Surgical treatment

Primary tumor focus removal is the main method of treatment for patients with oral cancer. The doctor removes the primary tumor using an en-bloc technique, without dividing it into fragments. In this case, the risk of recurrence is minimal. The scope of the surgical intervention is planned based on the data from an instrumental diagnosis.

Sometimes, the neoplasm is adjacent to the nerve, which does not exclude the perineural invasion of the tumor. In this case, the nerve is exposed above and below the neoplasm and resected to obtain a clean resection margin.

Doctors often have to remove a fragment of the bone tissue from the lower jaw. Surgeons perform a marginal, planar, or sagittal resection if the neoplasm involves or is adjacent to the periosteum. The degree of jaw resection depends on the severity of the lesion, which is determined before surgery using instrumental tests.

After the surgical intervention, the removed material is examined. The key to successful cancer treatment is a clean resection margin. The distance to the visible tumor should be at least 2 cm. The margin is considered clean if the distance from the border of the removed tissue to the cancer cells is at least 5 mm. If the distance is smaller, the margin is called close.

Cervical lymph node dissection is a stage of the operation involving the removal of cervical lymph nodes. The scope of lymph node dissection depends on the stage of the disease. If there are no clinical signs of metastasis, then the lymph nodes of the first three levels are removed. If metastases are found, then the lymph nodes of five levels are removed.

The lymph nodes are usually removed on one side only. But, if the thickness of the tumor, according to a computed tomography scan, exceeds 4 mm, then the lymph nodes on the other side are also removed, due to the high probability of micrometastases. Lymph node dissection not only allows doctors to accurately determine the stage of the disease in order to better plan the postoperative treatment, but also reduces the likelihood of tumor recurrence. In addition, a bilateral lymphadenectomy is required if the cancer has spread beyond the midline.

With a small tumor size – up to 2 mm, no lymph node dissection is required. In this case, the risk of any metastasis spread is minimal.

Sentinel lymph node biopsy is a high-tech procedure that replaces lymph node dissection in some patients. It is used in German hospitals. Doctors inject a radioactive substance into the tumor site, and then use a gamma camera to check which lymph nodes it accumulates in. These nodes are called sentinel nodes: they are the first to collect lymph from the tumor. The sentinel lymph nodes are then removed and examined. If there are no signs of cancer in them, then the cancer has not spread to the lymph nodes that are located farther from the tumor. Therefore, there is no need to remove them. If cancer metastases are detected in the sentinel lymph nodes, the patient undergoes cervical lymph node dissection in the standard scope.

Therapeutic tactics for inoperable tumors

If surgical treatment for cancer is considered impossible, the management of a patient differs, depending on their health status. The patient's general condition is assessed according to the ECOG (Eastern Cooperative Oncology Group) classification. The lower the score, the better the patient's condition.

The therapeutic tactics for the inoperable tumor are as follows: 

• ECOG 0-1 – induction chemotherapy, then chemoradiotherapy, after which, the question of the possibility of performing the surgical operation is reconsidered.
• ECOG 2 – external beam radiation therapy or polychemotherapy is carried out. 
• ECOG 3 – palliative radiotherapy or palliative chemotherapy (lower doses, fewer drugs to reduce the risk of side effects and complications).

Treatment of cancer recurrence

The best way for cancer treatment that has recurred after surgery is a second surgery. Nonetheless, it is not always possible. The doctor will only perform surgery if he believes that it is possible to remove the cancer, in order to achieve R0 status (total removal, without residual tumor left).

Treatment options for inoperable cancer recurrence are as follows: 

• chemoradiotherapy; 
• radiation therapy; 
• chemotherapy.

Treatment of cancer with distant metastases

Treatment options for stage 4 cancer with distant metastases are as follows: 

• surgery;
• radiation therapy;
• chemotherapy.

A surgical intervention is performed only if the doctor believes that the tumor can be removed with an R0 status. With a newly established cancer diagnosis, there may be a combined intervention. Doctors will simultaneously remove tumors from different parts of the patient's body. In addition, some patients will experience recurrences developed from distant metastatic foci, from the previously removed primary tumor. In this case, surgery to remove the metastasis is indicated if there are no signs of local cancer recurrence.

In the case of inoperable metastatic cancer, doctors irradiate the metastatic site using radiation therapy. But, if there are many metastases, only chemotherapy is conducted.

Radiation therapy as an independent treatment method

In some cases, radiation therapy is conducted without surgery. It can cure cancer, but this is unlikely. If the cancer is not completely cured, long-term survival of the patient is achieved, since a long-term remission of the disease will occur. The tumor is reduced in size, so the symptoms regress.

Radiation therapy options: 

• external beam radiation therapy – for the primary tumor and lymph nodes; 
• brachytherapy – contact irradiation with radioactive seeds introduced into the tumor (used for neoplasms up to 4 cm in size). 

If the patient's state of health allows, then chemotherapy is also included in the treatment regimen. The simultaneous use of two methods provides better results, but has a higher toxicity.

Why is it worth undergoing treatment in Germany?

Thousands of patients from all over the world travel to Germany for cancer treatment. Doctors with high reputability in the world of medicine work in this country, and state-of-the-art equipment is used in the hospitals here. Here are a few reasons for you to undergo treatment in Germany:

• the most cases of oral cancer are cured here;
• surgical treatment is possible even at an advanced stage, including in cases with a spread of distant metastases;
• high performance in the reconstructive stage of surgical intervention to restore all the functions of the oral cavity and dentoalveolar system;
• high performance of skin grafting to improve the person's appearance after surgery;
• the use of modern methods of radiation therapy, which have a minimal effect on healthy tissues, reducing the risk of post-radiation complications.

To undergo diagnosis and treatment of oral cancer in Germany, please use the Booking Health service. On the website you have the opportunity to see up-to-date and accurate information about the cost of treatment in Germany, compare prices in different German hospitals and book a medical care program at a favorable price. Diagnosis and treatment will be easier and faster for you, and the cost of treatment in Germany will be lower. You can see the average prices below:

• The cost of tumor resection and cervical lymph nodes dissection for oral cancer with metastases to lymph nodes is between 20,270 EUR and 32,700 EUR.
• The cost of chemotherapy for oral cancer is between 4,600 EUR and 5,000 EUR.
• The cost of chemoradiotherapy for oral cancer is between 20,400 EUR and 30,800 EUR.
• The average price of rehabilitation after oral cancer treatment is 1,190 EUR per day, the minimum price is 1,041 EUR per day, and the maximum price is 1,553 EUR per day.

You are welcome to leave your request on the website of the medical tourism operator, Booking Health. An employee will contact you, consult with you, and answer all your questions. We will take care of the organization of your trip abroad. We will provide the following benefits to you:

• We will select the best German hospital, whose doctors specialize in the diagnosis and treatment of oral cancer and achieve the best results;
• We will help overcome the language barrier and establish your communication with the doctor at the German hospital;
• The waiting time for diagnosis and treatment will be reduced, and you will receive medical care on the most suitable dates for you;
• We will reduce the price. The cost of treatment in Germany will be lower than usual due to the elimination of overpricing and coefficients for foreign patients;
• Our specialists will solve any organizational issues: paperwork, transfer from the airport to the German hospital and back, hotel booking, and interpreting services;
• We will prepare your documents and translate them into English or German. You do not have to repeat any previously performed diagnostic procedures;
• We will maintain contact with the German hospital after the completion of your diagnosis and treatment;
• We will arrange additional medical examinations and treatment, if required;
• We will buy your medicines in the other country and forward them to your native country.

While the best specialists in the world are taking care of your health, the Booking Health staff will help reduce your cost of treatment in Germany and take care of all your travel arrangements.

Authors: 

The article was edited by medical experts, board-certified doctors Dr. Vadim Zhiliuk and Dr. Sergey Pashchenko. For the treatment of the conditions referred to in the article, you must consult a doctor; the information in the article is not intended for self-medication!

Sources:

European Society for Medical Oncology

Cancer Research Institute

NORD - National Organization for Rare Disorders